The fifth Millennium Development Goal (MDG) aims to reduce maternal mortality by 75% by 2015. Early health indicators underscore poor maternal and child health conditions in developing countries like Bangladesh and India. According to a WHO-UNICEF-UNFPA-World Bank report, one in six women worldwide who die due to pregnancy-related causes lives in India. In 1990, Maternal Mortality Rate (MMR) in India was high at 570 per 100,000; by 2008, it had dropped to230 per 100,000. Research by Australian Aid (AusAID) and the United Nations Population Fund (UNFPA) indicates that maternal deaths in Bangladesh fell from 322 per 100,000 in 2001 to 194 in 2010, a decline of 40%. This article examines two approaches in Bangladesh and India that have made significant inroads to meet the MDG on maternal mortality.
Constraints to Achieving Better Maternal and Neonatal Healthcare
According to maternal and neonatal health information, the urban poor are two to three times worse off than the average statistics for urban areas. In urban slums, neonatal and maternal deaths occur due to unplanned deliveries, delays in reaching health facilities and deliveries conducted by untrained individuals. Ironically, this happens even when public health facilities are situated in close proximity to slums.
The cost of a hospital delivery is only one of the constraints. Dr. Armida Fernandez of the Mumbai-based Society for Nutrition, Education and Health Action (SNEHA) says that deep-rooted beliefs about reproduction can be a significant obstacle to hospital deliveries. She adds, “People have been born at home for centuries. For the poor, pregnancy and childbirth are physiological phenomena. They don’t view pregnancy as a disease, and hence, will not go to a hospital as they would for other illnesses. Other issues include transportation to the nearest health facility, pending work at home, and other children to care for.” Interestingly, most first-time mothers will visit a hospital for antenatal and postnatal care, but they will rarely do so for subsequent children.
A study of the urban poor in Bangladesh indicates that nearly 80% of deliveries are at home, aided by neighbors and relatives. Antenatal care coverage is 55% while immunization coverage is 63% in urban slums. Their reasons for not seeking healthcare and hospital delivery include inconvenient timings of the health centers and hospitals, long queues and difficulty in accessing healthcare at the time of delivery. Additionally, there are strong superstitions associated with pregnancy, which constrain pregnant women from moving out of their homes to visit health centers.
MANOSHI – Supplementing Public Infrastructure with Birthing Huts in Urban Slums
In 2006, the Bill and Melinda Gates Foundation partnered with BRAC to launch supplemental birthing huts that now operate in six city corporations in Bangladesh. In just 4 years, the program, named MANOSHI, has achieved the national target of bringing down maternal mortality rate (MMR) to 141 per 100,000 live births in areas where it operates. More importantly, the program has been able to educate the urban poor about pregnancy and the need for seeking skilled care.
MANOSHI aims to impact maternal and child health in Bangladesh’s urban slums by providing BRAC’s successful Essential Care Program model, which has been adapted to an urban setting. The program identifies pregnancies and follows up with mothers irrespective of their delivery service-provider decision. Pregnant women are told about BRAC birthing huts, which have a trained urban traditional birth attendant (UBA) and can provide expectant mothers with a private and hygienic delivery. The program has a referral system in place in case of complications, typically the local government-run health facilities under the Urban Primary Health Care Project (UPHCP). The program generates awareness about the need for antenatal and post-partum healthcare and encourages community action to address behavioral issues.
SNEHA – Improving Public Infrastructure by Setting Standards and Capacity Building
In India, public health infrastructure in cities is extensive. There are around 176 health posts, 150 dispensaries and 26 maternity homes located within the slums of Mumbai operating at the primary level. Secondary-level healthcare services include peripheral hospitals offering delivery services and other specialized treatments. The poor do not use this infrastructure for antenatal and neonatal care because these health centers operate with limited hours, often coinciding with timing for household chores or hours that an escort may not be available. As a result, women in urban slum areas turn to unqualified private doctors. Sub-standard quality is another significant reason for the poor to opt out of the public healthcare system.
SNEHA is an NGO working in India on initiatives to enhance health and survival of mothers. The organization works through community action to improve access to quality and standardized healthcare. SNEHA has two ongoing programs, the City Initiative for Newborn Health (CINH) and Sure Start, which aim to reduce maternal and neonatal mortality rates in urban slums. SNEHA’s initiatives focus on enhancing existing systems and institutional capabilities and infrastructure, an approach that differs from MANOSHI’s supplemental programs. CINH, for instance, partners with the Mumbai Municipal Corporation and the Lokmanya Tilak Municipal General Hospital Mumbai, and collaborates with public health posts, public maternity hospitals and tertiary hospitals on the supply side and with community-based organizations on the demand side. Sure Start also works at the community and system levels, with the stated objectives of increasing individual, household and community action and advancing systems to improve maternal and neonatal health.
SNEHA’s approach has been to assess gaps to achieving stated goals, and then understanding systems needed to reach these goals as well as analyzing the efficacy of systems currently on hand. The NGO’s initial research pointed to the need for developing standards and best practices, training of skilled persons to conduct deliveries and building a referral system. Addressing these gaps form the basic building blocks of SNEHA’s maternal and neonatal health programs.
The research team also found that many health posts were not providing antenatal and postnatal care, causing a higher load at the busier centers and hospitals. Given the operational and governance issues with public provision of health services, it would seem MANOSHI offers the more sustainable modelby setting up a micro-level parallel healthcare system. Dr. Fernandez disagrees and cites some examples of how programs have worked within the public infrastructure in India and Sri Lanka. She says: “Delivery is safe when there are formally trained attendants. In Sri Lanka, there is a system of midwife nurses. Tamil Nadu has been very successful in providing trained nurses for delivery. Kerala is another example. So it is possible to make the public systems work.” She also refers to the success of conditional cash transfer initiatives by the Government of India, specifically the Janani Suraksha Yojana, which offers cash benefits for households availing of antenatal care, hospital delivery and post-partum care.
Financial constraints can be more easily dealt with than the other issues in maternal healthcare. Risk pooling, conditional cash transfers and voucher systems are some ways to bring the urban poor to hospitals for deliveries.
While government and private sector efforts have been successful in reducing maternal and neonatal mortality rates, they have been less successful in bringing about changes in the mindset of people. The urban poor currently avail of maternity and neonatal healthcare services only because they are convenient and free. Even though proper healthcare results in lower mortality indicators, major motivating factors for the poor focus on the economics of the situation: many use the services because they can earn money, as in the case of India’s Janani Suraksha Yojana. A survey among beneficiaries and non-beneficiaries of MANOSHI in Bangladesh found that respondents complained about the lack of doctors and medicines at the birthing huts. Beneficiaries also resist referrals as they are not wholly reimbursed for the additional expense by the program. Clearly, mindsets need to change if MANOSHI and similar grant-based programs seek long-term financial sustainability of their own.
Dr. Fernandez says that SNEHA’s model is more viable in the long-term because of its focus on working with public infrastructure. Public systems can be made effective by community and NGO efforts. She also stresses the need for holistic solutions to maternal and childcare issues. SNEHA’s programs focus on many areas, ranging from domestic violence, adolescent and reproductive health, as well as maternal and neonatal health. She says: “A newborn’s low birth weight is not something we can tackle during the antenatal period alone. This is determined by the mother’s health during her adolescence. Sex and reproductive health is a major factor. Similarly, domestic violence has a role to play in maternal and neonatal health.” For the future, Dr. Fernandez calls for solutions that focus on holistic solutions; good quality, conveniently located public health systems; building capacity by increasing the number of colleges training skilled staff for deliveries; and setting and adhering to quality standards in maternal and neonatal healthcare.
The opinions expressed on the Searchlight South Asia site are solely those of the authors and do not necessarily reflect the positions of the Rockefeller Foundation.